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South Dakota rates for HCPCS 15150

Tissue cultured skin autograft, trunk, arms, legs; first 25 sq cm or less

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$593.12 / $663.20 / $663.20
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$520.26 / $593.12 / $663.20
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,266.60 / $1,544.96 / $1,931.19
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$747.35 / $1,040.52 / $1,788.56
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$679.62 / $1,554.04 / $5,127.12
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,207.00 / $1,573.40 / $2,214.98
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,266.09 / $1,547.30 / $1,915.22
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$758.71 / $1,155.18 / $1,375.31
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,000.00 / $2,000.00 / $2,000.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$786.02 / $1,413.38 / $1,905.74
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,148.40 / $1,405.10 / $1,542.20